Conscience

For more than one reason, my conscience has been on my mind this week.

As Canada prepares itself for Physician Assisted Suicide (PAS), a philiosphical debate has been resurrected about the obligation of doctors to the healthcare system within which they work. And there seems to be strong encouragement for the view that we are agents of the legal system within which we work and, therefore, have no legitimate right to conscientiously object to performing healthcare that is endorsed by the state.

Many of the arguments are cohesive and water-tight in a philosophical sense but it raises a question that I often ask myself as I make personal sacrifice for my profession…’What about me?‘. In the current literature, there is a distinct lack of empathy for the practitioner who is being asked to take on a life-altering activity on a potentially regular basis.

I’m pro-choice when it comes to death. It’s my death and I don’t know why the state needs to take such a vested interest in it. Foul play apart, lack of capacity apart, the decisions to be made are mine and mine alone. I may choose to involve my family should I be lucky enough to still have one at that juncture in my life. But in order to die how and where I desire, I may, ultimately, need to take some matters into my own hands. It would be preferable were our law to endorse this right, but, when facing death, remaining within the law will no longer be my main concern. I won’t need my GMC registration once I’m dead.

In my doctoring life, I am excruciatingly aware of my beliefs and the legal system within which I presently work. Let me be clear, for the record, I do not advocate or explore issues around Euthanasia or Physician Assisted Suicide with patients. This is currently illegal. The fact that I disagree with our present law does not alter my professional practice.

However, in my teaching role, and for over a decade, I have explored in great detail the permutations and contradictions of our present approach to end of life care and choices. From dialogue with hundreds of students, we have come to, on a philosophical basis at least, an equilibrium of belief where respect for autonomy trumps the state’s right to control choice. Students’ level of caution and personal morality varies greatly but most agree that the ‘death’ itself belongs with the patient and their loved ones.

Most of our students advocate a change in UK legalisation in favour of Active Euthanasia, knowing that for some patients this will need Physician Assisted Suicide, and I don’t think they’re saying that just to keep me happy!

Where our discussions seem to lose consensus is once we start to approach PAS on a pragmatic level.

Who is going to actually perform the Physician Assisted Suicide?

Will my 10.30am appointment be a pill check, my 11.15am the ‘PAS slot’?

And, this is definitely where I start to struggle. I can’t marry up in my mind the commitment to my living patients over those who wish to die.

How will my patients feel about me if I help people to die and they disagree with this action?

How would performing such an act affect me as a person and as a doctor?

Could sufficient reassurance be provided to stop me from lying awake at night wondering if it was the right decision?

What if I had never met the patient before I was asked to euthanase them?

What if the panel who had overseen the decision turned out to be incompetent…or flawed…or corrupt?

What if, ultimately, despite strong protest in favour of choice, and heartfelt beliefs that patients know themselves best, I don’t want to be the one to do the killing?

With, or without, robust and unrefutable arguments to support my instincts and strong sense of self, isn’t that still my right? Or can a society, not necessarily secular in its legal derivation, genuinely compel me to act in its best interests?

Does it add to my defence that I am consistently contrary? I feel similarly about abortion. Again, pro-choice, and disgusted to think of the denigration of woman internationally from lack of this choice, I am admiring of my colleagues who perform abortion but have guided my own career choices away from regular contact with the procedures involved. Although happy to counsel and facilitate women at very difficult and challenging times in their reproductive lives, I believe that I would be altered as a person if I performed abortion on a regular basis. I fully accept that this may be described as cowardly, or seen as ducking my responsibility within the profession, but is it not okay to have that level of self-knowledge and reflection? The reasoning may be less moral and more visceral but I have also chosen against sawing bones or dealing with men’s bits on a regular basis too. It is perfectly possible to guide one’s choices to have a fulfulling career, avoiding paths where one’s conscience might hinder a patient’s right to choose certain procedures and care. And, I do believe that this is genuinely okay whilst we have colleagues who can countenance their roles and, I hope I’m not being naïve in saying, bear the consequences of their working days. So long as patients can have their choices met by some doctors, why do we ever need to suggest that all doctors have to provide all services?

And so, on the matter of Physician Assisted Suicide, I think that it is okay to say “listen to your conscience” and live within your own moral compass, so long as you endeavour to facilitate your patient’s preferences, as guided by the law where you practice your profession. Don’t be bullied to do something that will fundamentally alter you as a human being. Just don’t obstruct the autonomous choices of your patient and their right to die.

If you are not the doctor who will, find a doctor who is. And, if there is no doctor who will, then we really do have to go back to the drawing board, because a patient always has the right to ask, but a doctor with, or even without, professional autonomy, on matters so large, should also have the right to decline.